Lecture 2 case history Flashcards
What is a patients consitituion?
how they generally feels, fever, well, achy
T/F you want to review the 10 body systems with the patient
T
To record follow up case history and problem focused history use SOAP-what does it stand for
subjective-chief complaint
objective-exam observations and findings
assesment, diagnosis
plan, treatment
tentaive diagnosis with rings around lights/streaks from light
corneal swelling, dirty contacts, cataracts, dry eyes,
If a shadow occurs around letters most likely (myopia/astigmatism/cataracts/hyperopia)
cataracts, astigmatism
T/Fwhen a pt sees flashes of lights its called photopsia
T
When a pt sees floaters , you want to as them what?
recent onset or longstanding
changes in shape/size/frequency
-associated with flashes
T/f if pt has longstanding unchaned floaters it is less concerning
T
T/F new onset, changing or assiated with flashes may make retinal exam a priority
T
If diploplia is monocular what are the possible problems?
(retinal/optical/vergence/neurological )-pick two
optical or retinal
If diploplia is binocular what are the possible problems?
(retinal/optical/vergence/neurological )-pick two
vergence, neurologic
When words blur after 10+20 minutes of new work and are blurry at distance and feel strained after near work describes (accommodative dysfunction/myopia/hyperopia)
accommodative dysfunction
- Double vision at night
- Double vision when reading
- Discomfort around eyes
- Word run together or move when reading
- Skipping lines or losing place when reading
binocular dysfucniton/vergence dysfunciton
Vague eye discomfort arising from use of the eyes may consist of eyestrain, headach, and or browache desribes :
(astigmatism/asthenopia/aspirate)
asthenopia
Abnormal sensitivity to light
Usually associated with infection /trauma
descibes (ashthenopia/photophobia/ocular discomfort)
photophobia
-_____can have a multitude of causes
Related/unrelated causes
Take all complaints of ____ very seriously
Explore possible reasons for the ____ in the ____history
(fill in blank with the same word for all)
headache
Refer/consult
Visual Field exam
Neuro- exam
–ALL are test strategy for ?
headaches
Testing Strategy for (photophobia/accomodation)
Dry eye evaluation
Careful evaluation for uveitis
photophobia
Testing Strategy for (accommodative dysfunciton/myopia/hyperiopia)
Visual Efficiency Evaluation work up for patient <35y
Near work/presbyopia work up for patient over 35y
accommodative dysfunction
T/F case history only happens at the very beginning of an exam
F Case history continues throughout the exam
- Computer Users
- Contact Lens Wearers
- “Red Eye”
- Geriatric
- Pediatric
- Trauma
- Headaches
- -all of these describe?
special case histories
- Fatigue or strain
- Brow aches or head aches
- Blur at near
- Blur at distance at the end of the day
- Dry eye complaints: gritty, sandy
- -all describe symptoms of (trauma/red eye/computer users)
computer users
Is there a source of intrusive light behind you?
How is the ambient lighting in your office?
How often do you take breaks?
–all these questions would be asked to a (trauma pt./computer user/red eye pt)
computer user
-How long have you worn them today?
-Do you nap in your lenses?
-How many nights a week do you sleep in your lenses?
-Have you ever been treated for a red/ eye/ infection/ abrasion?
-How do you clean and disinfect your lenses? -Which care system?
-Do you currently have any problems with your lenses/wear?
ARe some questions to ask ___ wearers
CL
